Alternative Format Request Form
Disability Resources--Northern Arizona University, P. 0. Box 5633, Flagstaff, AZ 86011, (928) 523-8773, afp@nau.edu
Date Requested:_____________ Time:_______AM or PM
---------------------------------------------------------Above dotted line is for Disability Resources Office Use Only----------------------------------------------------------
Name of student:______________________________________________________________________________
Student ID:_______________________
Class Information:
E-mail Address:_______________@nau.edu
Class Name:_____________________________________________________________________
Class Number (example: PSY620): ___________________________ Section # _________________________________
Instructor:________________________________________________ Semester: ________________________________
Campus: ___ Flagstaff
___ Extended Campus
___ E-Learning/Online
Alternative Format Requested:
E-Text___
MP3___
Braille___
Captions ___
What device/software will you be using to read with?
Jaws___
Kurzweil ___
Personal CD/MP3 ___
Other __________________________
Additional Requests for JAWS users only: (All texts will only include the main body unless otherwise noted)
Picture Descriptions ____
Picture Captions____
Tactile Graphs____
Requests for alternative format must be made in a timely manner prior to when the materials are needed.
Submitted literary text only (no graphics/math/music) materials 10 pages or less will be translated in a 72-hour
turnaround period upon date of receipt. All other submissions will be translated within a reasonable time period.
Requests for BOOKS must be made EIGHT WEEKS prior to date needed for timely delivery.
ALL Class and Book information MUST be provided before we can process this request.
If requesting books, use the format below:
Book Information:
Title: ______________________________________________________________ _________________________
Author(s) ___________________________________________________________________________________
Publisher: ___________________________________________________________________________________
Copyright Date: _____________ Edition:____________ ISBN#:______________________
If requesting text other than a book, use format below:
Title of Material Submitted: _______________________________________________________________
Format of Material Submitted: Text File _____
Hardcopy _____ Video _____ Other ______________
Multi-Media link (youtube, etc.) ______________________________________________________________
X:\Shares\Debra\Forms\Alternative Format Request Form
Disability Resources Staff Use Only
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Disability:
Blind ___ Visually Impaired ___ LD ___ Deaf/HH ___
Is text available from:
Blio: Yes ___ No ___
CafeScribe: Yes ___ No ___
If Yes, student notified (date): _________________________________________
Available in DR Library:
Yes ___ No ___
Requested from QuickBase (date): _____________________________________
Available: Yes ___ No ___
Received/Downloaded (date): ________________________________________
Requested directly from publisher (date): _______________________________
Available: Yes ___ No ___
Received/Downloaded (date): ________________________________________
Need to Purchase: Yes ___
Date Requested: ___________________________________________________
Date Received: ___________________________________________________
Conversion assigned to: _____________________________________________
Date: ____________________________________________________________
Conversion Completed:
Date:
Complete Text ____________________
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Chapter: _________________________
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Chapter: _________________________
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Uploaded:
Date:
Complete Text: ___________________
________________________
Chapter: _________________________
________________________
Chapter: _________________________
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Chapter: _________________________
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Chapter: _________________________
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Chapter: _________________________
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Chapter: _________________________
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Chapter: _________________________
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Chapter: _________________________
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Student notified to login to Alfresco (date): _______________________________
Student responded (date): _____________________________________________
E-mail with book link sent to student (date): ______________________________